Preoperative Medical Care of the Surgical Patient

Preoperative Medical Care of the Surgical Patient Byron Turkett, PA-C, MPAS Chief PA, Division of Trauma/Critical Care University of Tennessee Medical...
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Preoperative Medical Care of the Surgical Patient Byron Turkett, PA-C, MPAS Chief PA, Division of Trauma/Critical Care University of Tennessee Medical Center Knoxville

UTMCK

Introduction • “A chance to cut is a chance to cure” • “Nothing heals like cold, hard steel” • Surgery = stress and insults – Physiology of surgery – Maximize pre-operative condition of patient – Preoperative evaluation: H&P – Perioperative care: think of what can kill first...

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Perioperative medical care: • • • • • • • • •

Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK

Perioperative medical care: • Surgical emergency – Trauma

• • • • • • • •

Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK

Surgical Emergency • 76 yo WM “coded” in front of HLVI building; ACLS followed x 20 min with intermittent pulse return; intubated, IVs placed, brought to ER; SBP 60 with HR return • MICU team called to eval; pt started on Neo-synephrine for bp • Surgery called when Hct returned 14.2 UTMCK

Surgical Emergency • What do you want to do? • HISTORY

& PHYSICAL

• History? (tailor to situation) • VS 70/20 135 16 (IMV) 36.4 • “Pt is unconscious, intubated, not moving - abdomen is very distended, quiet BS”

• Keep DDx in mind during H&P • Why can’t he keep a bp?

• What do you want to do about it? •Risk of doing something vs. risk of doing nothing?

• What do you need to do before surgery? UTMCK

Surgical Emergency • AMPLE history – A llergies – M edications – Past medical history – Last meal – E vents preceding the surgery

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44 yo WF who presented to ER today with RUQ three days ago. RUQ U/S showed gallstones. CT scan of the abdomen/pelvis showed gallstones.

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“Pre-op this patient” • • • • • • • • •

History and physical Informed consent for operation and blood Type and screen or type and cross CXR (age greater than 20) 12-lead ECG (age greater than 40) BMP, M/P, CBC, PT, PTT, INR NPO after MN (IV Fluids) Pre-op Note Pre-op Orders (hep 5000 units SQ, Abx, beta blocker) • ?Bowel Prep UTMCK

Pre-Op Labs and Studies • CBC – Anemia – Malignancy – Renal Disease – Cardiac Disease – Pregnancy

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Pre-Op Labs and Studies • Chemistry – Diabetes – HTN – CVD – Renal Disease – Liver Disease – Diuretic Use – Elderly UTMCK

Pre-Op Labs and Studies • UA – Rarely Needed, only if symptomatic

• CXR – Rarely indicated as screening tool

• EKG – – –

Males >40, Females >50 ?baseline History of CVD, DM. HTN Planned thoracic, aortic, intraperitoneal or emergency surgery UTMCK

Symptomatic Cardiac Disease Work Up • • • • • • • •

History of event Physical exam 12-Lead ECG CXR ABG Cardiac Panel BMP, M/P, CBC, PT, PTT, INR Chart Review UTMCK

Finding Cardiac Disease in the Asymptomatic Patient • • • • • • • •

Abnormal vital signs Assess functional status Tachycardia JVD at 30 degrees Bruits Pedal Edema Rubs and 3rd heart sounds Murmurs – Most apical systolic murmurs are innocent – Any murmur with a thrill or any diastolic are NOT innocent UTMCK

Cardiac disease in peri-op period MI

arrhythmias

CHF

• CAD can cause any of these • Risks for CAD:

XX

– age, sex, HTN, XOL, DM, tobacco

• Modify those risk factors you can... medical therapy

will cover later. . . UTMCK

Coronary Artery Disease •

Definition of CAD....

• Physiology of surgery: – ↑ myocardial oxygen demand – ↑ catecholamines: ↑ HR, ↑ contractility, ↑PVR – ↑ HR also causes decreased diastolic filling • Coronary arteries fill in diastole • Less blood flowing in coronaries: less myocardial O2 supply UTMCK

Myocardial Infarction • Pt without risks has 0.5% chance of MI – Pt with risks has 5% chance of perioperative MI

• Perioperative MI has 17-41% mortality • CAD causes MI....look at PMH • Risk stratifications: MI w/in 3 months of OR

27% reinfarction rate

MI 3-6 months before OR

10% reinfarction rate

MI >6 months of OR

5-8% reinfarction rate*

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Prevention of perioperative cardiac events 1) Wait 6 months if possible 2) Beta-blockade* • • • •

200 pts with CAD or risk factors for CAD atenolol pre-op and peri-op in ½ MI reduced 50% in first 48h 2 year mortality 10% vs 21%

3) Maintain peri-operative normothermia •

↓ cardiac events, esp. arrhythmias

4) Treat peri-operative hypertension * Mangano NEJM 335:1713, 1996.

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Prevention of perioperative cardiac events 7) Watch for and treat arrhythmias

Causes?

Drugs, electrolytes, ischemia, fluid shifts, body T

Treatment?

underlying cause, rate control, conversion

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Perioperative medical care: • • • • • • • • •

Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK

Pulmonary disease • Patient-related risks – Chronic lung dz – wheeze, productive cough – Smoking – General health – Obesity – Age? • separate from others?

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Pulmonary Disease • Procedure related risks – Type of anesthesia • GETA alone ↓ FRC 11% • inhibited cough/mucociliary function

– Surgical site • Increased with midline incision or dissection of upper abdomen and with thoracotomy

– Duration of surgery • Longer duration of GETA increases risk of pulmonary complications • V/Q mismatching due to positioning UTMCK

Modifiable Pulmonary Risks • Obstruction to flow – COPD – Asthma

• Obesity physiology – – –

↓ lung capacity, FRC, VC ↑ WOB, ATX, Secretions hypoxemia

• Tobacco – Rel Risk 2-6x > vs Non Smoker – Definition of “stopped smoking”.... – “When was your last cigarette?” UTMCK

Pre-operative risk assessment: pulmonary function • Patient history – Functional Status – Unexplained dyspnea, cough, reduced exercise tolerance, OSA

• Physical exam: – Wheeze, rales, rhonchi, ↑ exp time, ↓ BS, loose rattle w/forced cough (can reveal underlying pathology) – 5.8x more likely to develop pulmonary complications* – FEV1 Screening

• Pre-operative CXR over 40, without a baseline should be considered • ABG – No role for routine use * Lawrence et al Chest 110:744, 1996

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Perioperative medical care: • • • •

Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction – Dialysis dependent

• • • • •

Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy UTMCK

Renal Dysfunction • • • •

Not all renal failure is oliguric H&P Check BUN/Cr, CBC Assume DM have CRI – Volume status • Overload and hypotension are common

– Electrolytes.....sequelae? • Watch K, Ca, Mag, Phos, HCO3

• Drug metabolism – Be aware of nephrotoxic agents – CAUTION w/Succinylcholine UTMCK

Renal dysfunction • Dialyze preop to improve electrolytes, volume status • No K+ in MIVF • Very judicious MIVF while NPO • Altered drug metabolism • Altered platelet fxn UTMCK

Perioperative medical care: • • • • • • • • •

Surgical emergency Cardiac disease Pulmonary disease Renal dysfunction Liver dysfunction Diabetics Bleeding disorders Malnourished Pregnancy

Why does hepatic disease cause coagulopathy?

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Child-Pugh Criteria for Hepatic Reserve Measure

A

B

C

Bilirubin

3.0

Albumin

>3.5

2.8-3.5

6

None

Slight

Moderate

Neuro

None

Minimal

“Coma”

Mortality

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